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Chronic Care Model Wiki
Chronic Care Model The Chronic Care Model (CCM) is an evidenced based framework that was developed and disseminated in the early 90s by Ed Wagner, MD, MPH and his team at MacColl Center for Health Care Innovation. Before the CCM launched, much of the care provided to chronically ill patients was acute or reactive (Kaiser Permanente Washington Health Research Institute, 2019). The basis of the CCM is proactively managing patients with chronic conditions such as hypertension, heart failure, diabetes, and chronic obstructive pulmonary disease. To successfully manage chronic diseases, patients must be provided with self-management skills (Barletta, Profili, Gini, Grilli, Rampichini, Matarrese & Francesconi, 2017) and specialized coordination of interdisciplinary services throughout their lifetime with the disease (Mohomed & Asmall, 2017). The CCM strives to optimize six interrelated parts of the health system to prevent & manage chronic disease: # Community resources and policies # Health system organization # Self-management support # Decision support # Delivery system design # Clinical information systems (Baptista, Wiens, Pontarolo, Regis, & Reis, 2016) Organizations must focus on these six areas, as well as develop productive interactions between patients who take an active part in their care and providers who have the necessary resources and expertise. What are Chronic Diseases? * Hypertension (High Blood Pressure)- Approximately 1 in every 3 adults in the United States have high blood pressure, and only 54% of these people have their blood pressure under control (Centers for Disease Control, 2018). High blood pressure increases your risk of having a heart attack or stroke. Risk factors for high blood pressure include age, family history, physical inactivity, obesity, alcohol consumption, and tobacco use (Centers for Disease Control, 2018). High blood pressure can be managed by making healthy lifestyle choices such as physical activity and eating a healthy diet. It can also be managed by controlling diabetes and blood pressure through medication and consulting with your healthcare providers. * Diabetes- The prevalence of diabetes specifically type 2 has been increasing each year world wide. Diabetes is one of the most common chronic diseases. Approximately 425 million people have diabetes (Kong et al., 2018). Risk factors for developing type 2 diabetes include alcohol consumption, diet, physical inactivity, obesity, blood pressure, blood glucose, and serum lipid levels (Kong et al., 2018). Having diabetes puts you at risk for developing other chronic conditions such as high blood pressure and heart disease. * Heart Disease- The most common type of heart disease is coronary artery disease which alters blood flow to the heart (Centers for Disease Control, 2018). Is the leading cause of death among men and women in the United States alone, 630,000 Americans will die each year from heart disease (Centers for Disease Control, 2018). Like many other chronic conditions, risk factors for heart disease include smoking, high blood pressure, elevated LDL cholesterol, obesity, physical inactivity, poor diet, and diabetes (Centers for Disease Control, 2019). An important way to lower your risk of developing heart disease is making healthy living choices and managing chronic conditions you already may have. * Arthritis- Approximately 54.4 million Americans are affected by arthritis, and it is not only one of the most common chronic conditions but is also a major contributor to chronic pain (Centers for Disease Control, 2018). There are many different risks factors for arthritis and some such as age, gender, and genetics are out of your control. Modifiable risk factors include tobacco use, obesity, occupation, and joint injuries (Centers for Disease Control, 2018). * Chronic Obstructive Pulmonary Disease (COPD)- Many people are unaware they have COPD. COPD includes chronic bronchitis and emphysema, and approximately 15.7 million Americans report being diagnosed with COPD (Centers for Disease Control, 2018). Occurs in more likely in the older population and can be contributed to smoking use, asthma, and certain working conditions. * Depression - approximately 7.6% of Americans aged 12 and have depression (moderate or severe symptoms in the past 2 weeks. Approximately 3% of Americans aged 12 and over had severe depressive symptoms and report difficulties in work, home, and social activities. It is a serious medical illness with mood, cognitive, and physical symptoms. Depression is associated with higher rates of chronic disease, increased health care utilization, and impaired functioning (Coventry, Hudson, Kontopantelis, Archer, Richards, Gilbody, Bower, 2014). Rates of treatment remain low, and the treatment received is often inadequate. Studies have shown that the most effective treatment for depression, especially for severe depression, is a combination of medication and therapy. (Centers for Disease Control, 2018). Who has Chronic Diseases? As our population ages, the prevalence for Americans living with chronic conditions increases. Chronic diseases are the leading cause for death and disability of Americans (Centers for Disease Control, 2018) and the World Health Organization reports as many as 35 million people per year die from chronic diseases worldwide (Nasrabad, 2017). (Photo obtained from CDC on January 22, 2019) Benefits of the CCM * The Chronic Care Model has been shown to improve the quality of care provided and ultimately the overall health outcomes in patients ( Robusto, F., Bisceglia, L., Petrarolo, V., Avolio, F., Graps, E., Attolini, E., & Lepore, V, 2018). * Using the CCM in primary care settings has been shown to be cost effective especially with patients suffering from COPD, in which research has shown these patients to have a lower rate of inpatient hospitalization, as well as a shorter length of stay (Krucien, Le Vaillant, & Pelletier-Fleury, 2015). * Hospitalization and rehospitalizations of patients due to chronic illness are known to be financially burdensome to patients and families. The CCM helps alleviate some of these unnecessary acute medical expenses (Nasrabad, 2017). * Chronic diseases are largely responsible for the nation's $3.3 trillion health care costs annually therefore proactively treating these conditions with the CCM can lead to lower spending and health care associated costs (Centers for Disease Control, 2018). The Chronic Care Model & Primary Care * Establishing a partnership between the provider and the patient provides support for those with chronic illness. This relationship assists patients to develop self-care management skills and a means of coping with challenges. * The time available in primary care allows for recognition of symptoms, addressing future problems, and developing a realistic plan of care that works for the patient (Managing chronic disease in affordable primary care, 2018). * CCM is used in the primary care setting to have patients become involved with the management of their chronic illness, working with the physician and the rest of the healthcare team to improve patient care, and enhance the patients quality of life (Krucien et al., 2015). About the Authors This Wiki has been brought to you by the following Touro University Nevada MSN Family Nurse Practitioner Students: Katie Bass, Nicole Castellano, Jennifer Jipson and Sarah Riopelle References Baptista, D.R., Wiens, A., Pontarolo, R., Regis, L., & Reis, W.C.T. (2016). The chronic care model for type 2 diabetes: a systematic review. Diabetology & Metabolic Syndrome, 8. Retreived from https://search.proquest.com/docview/1771273494?accountid=14375 Barletta, V., Profili, F., Gini, R., Grilli, L., Rampichini, C., Matarrese, D., & Francesconi, P. (2017). Impact of Chronic Care Model on diabetes care in Tuscany: a controlled before-after study. European Journal of Public Health, 27(1), 8–13. https://doi.org/10.1093/eurpub/ckw189 Centers for Disease Control. (2018, November 19). About Chronic Diseases | CDC. Retrieved from https://www.cdc.gov/chronicdisease/about/index.htm Coventry, P. A., Hudson, J. L., Kontopantelis, E., Archer, J., Richards, D. A., Gilbody, S., . . . Bower, P. (2014). Characteristics of effective collaborative care for treatment of depression: A systematic review and meta-regression of 74 randomised controlled trials.'' PLoS One, 9''(9) doi:http://dx.doi.org/10.1371/journal.pone.0108114 Kaiser Permanente Washington Health Research Institute. (2019). Edward H. Wagner, MD, MPH | KPWHRI. Retrieved from https://www.kpwashingtonresearch.org/our-research/our-scientists/wagner-edward-h/ Kong, J.-X., Zhu, L., Wang, H.-M., Li, Y., Guo, A.-Y., Gao, C., … Patrick, D. L. (2019). Effectiveness of the Chronic Care Model in Type 2 Diabetes Management in a Community Health Service Center in China: A Group Randomized Experimental Study. Journal of Diabetes Research, 1–12. https://doi.org/10.1155/2019/6516581 Krucien, N., Le Vaillant, M., & Pelletier-Fleury, N. (2015). What are the patients’ preferences for the Chronic Care Model? An application to the obstructive sleep apnoea syndrome. Health Expectations, 18(6), 2536–2548. https://doi.org/10.1111/hex.12222 Mahomed, O. H., & Asmall, S. (2017). Professional nurses’ perceptions and experiences with the implementation of an integrated chronic care model at primary healthcare clinics in South Africa. Curationis, 40(1), 1–6. https://doi.org/10.4102/curationis.v40i1.1708 Managing chronic disease in affordable primary care. (2018). The Journal for Nurse Practitioners, 14(6). doi:http://dx.doi.org/10.1016/j.nurpra.2018.03.007 Nasrabad, R. R. (2017). Introducing a new nursing care model for patients with chronic conditions. Electronic Physician, 9''(2), 3794–3796. https://doi.org/10.19082/3794 Robusto, F., Bisceglia, L., Petrarolo, V., Avolio, F., Graps, E., Attolini, E., … Lepore, V. (2018). The effects of the introduction of a chronic care model-based program on utilization of healthcare resources: the results of the Puglia care program. ''BMC Health Services Research, 18(1), 377. https://doi.org/10.1186/s12913-018-3075-0 Insert non-formatted text here Category:Browse